| NPI | 1700098951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: AZ ATR-001668) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: AZ MT-25078) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2020-03-27 |